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The Ultimate Step 3 Case Simulations Study Guide

14 min


A medical resident studying for his Step 3 exam in front of a laptop and textbook.


If you’re reading this, you’re likely preparing for the 3rd and final step of the USMLE exam series, congratulations! You’ve done countless multiple-choice questions for USMLE Step 1, Step 2, and shelf exams and are ready to finish this final step. But wait, the USMLE decided to throw you a curveball, the case simulations. In this blog, we will cover the basics you need to prepare for the USMLE Step 3 case simulations!


Key Considerations for USMLE Step 3 Case Simulations


When approaching the case simulations for USMLE Step 3, it’s important to have a systematic approach to each case. Similar to real-life patient care in the hospital, having a system ensures you don’t miss anything. That being said, there are a couple of key differences between real patient encounters and case simulations. These are worth emphasizing up front and should inform your approach to the cases.


  • Use of Tests and Interventions


You are generally not penalized for unnecessary tests as long as they’re not invasive. In other words, cost-effective care or efficient use of hospital resources does not always earn you points. So, if you’re on the fence about whether or not to order a certain test, ORDER IT! It may provide important data to come to a correct diagnosis or rule out an item on your differential diagnosis to earn you points. The exceptions are tests and interventions that are invasive.  You will lose points for unnecessary invasive tests. 


  • Health Maintenance and Vaccines


You should always think about vaccines and other health maintenance, and ORDER them. Now perhaps this point should be true in real-life clinical encounters. However, generally in high-acuity environments such as the Emergency Department or Intensive Care Unit, advising patients on smoking cessation or giving them their Shingles vaccine is generally not the first thing on your mind. However, for the case simulations, you should always remember to go through health maintenance guidelines for each case and order the appropriate screening tests or vaccines at the end of the case, no matter the reason for their presentation!


  • Treatment of Symptoms


Always treat symptoms (in addition to the underlying cause). In real-life encounters, the decision of whether or not to treat pain or fever is more nuanced since you may not always want to mask these symptoms. However, for the USMLE case simulations, always treat these symptoms to maximize your points.



A Systematic Approach to Step 3 Case Simulations


All that being said, let’s jump into a systematic approach to cases that I use with my students. First, here is the list of things I’ll order for everyone:

  • Physical exam: All of them. Like I said earlier, you’re not penalized for unnecessary tests unless they’re invasive and that applies for physical exams as well, so you might as well do all of them in case any are relevant even for ruling out something on your differential diagnosis. 
  • Pulse Oximetry: You’ll realize that an oxygen saturation is not a part of the routine vitals presented for each case. Everyone should get a pulse oximetry to check their oxygen level. 
  • Labs: Point-of-care glucose, complete blood count with differential, complete metabolic panel, magnesium, thyroid stimulating hormone, EKG. 
  • Pregnancy test: Every case with a patient who could be pregnant should get a urine and/or serum pregnancy test.


Order Grouping for Efficient Case Management


In addition to those orders, I like to use the following buckets by which to group the various orders I’ll be putting in throughout the case. In the beginning, I think it’s helpful to write these bolded elements as columns on a sheet of paper. Fill this out as you go through the case so you can keep track of them. Gradually you’ll be able to keep a mental record of all of this without having to write everything down while working through Step 3 case simulations.


  • Diagnostic orders for the chief complaint: Order diagnostics for each item on your differential diagnosis based on the chief complaint.
  • Diagnostic orders for the likely diagnosis: Once you have an idea of the likely diagnosis, you should order all the diagnostic testing that is part of the standard of care for that condition.
  • Therapeutic orders for symptoms: When the chief complaint or HPI describes different symptoms, they should be addressed.
  • Therapeutic orders for the likely diagnosis: Once you have an idea of the likely diagnosis, you should order all the therapeutic interventions to adequately treat that condition.
  • Health maintenance: No matter what the chief complaint or the acuity of the condition, during the final 2 minutes, you should order all the appropriate health maintenance tests and vaccines and advise the patient appropriately.



Example Orders for Different Scenarios in Step 3 Case Simulations


Here are some examples of the above items. These are by no means exhaustive, but this framework will provide a useful template as you practice going through case simulations. 


Diagnostic orders for the chief complaint:


Let’s say someone comes into the ER with a chief complaint of abdominal pain. The DDx includes (among other things): pancreatitis, gastritis, gastric ulcer, cholecystitis and other biliary pathologies, hepatitis, various types of colitis, cystitis, nephrolithiasis, and pyelonephritis.


For each case of abdominal pain, I would order the following at the minimum in addition to the basic labs I would order for everyone (as listed above): lipase and amylase, abdominal x-ray, abdominal ultrasound or CT, liver function tests, rectal exam (in physical exams), urinalysis, and urine culture. I would not order an endoscopy or colonoscopy until after the above workups and only if the data gathered thus far suggests an intraluminal pathology after ruling out others, given that these are more invasive. 


Diagnostic orders for the likely diagnosis: 


Let’s say you have a case of altered mental status that you suspect is secondary to a stroke based on HPI and neurological exam. It’s important to order all the appropriate diagnostics for a suspected case of stroke. 


At the minimum, I would order the following: a non-contrast CT of the head to rule out a bleed, an MRI of the brain to diagnose the stroke, a CTA/MRA/ultrasound of the head and neck to assess for a large vessel occlusion, a transthoracic echocardiography with bubble study to evaluate for a cardiac thrombotic source as well as a patent foramen ovale, and a hemoglobin A1c and lipid profile to optimize risk factors for secondary prevention. 


Therapeutic orders for symptoms: 


  • If pain or headache, give them morphine or another opioid (or another pain reliever).
  • If fever, give acetaminophen (or another anti-pyretic).
  • If nausea, give ondansetron (or another anti-emetic). 
  • There are many others throughout the Step 3 case simulations, but here are some examples. Be sure to address each complaint!


Therapeutic orders for the likely diagnosis: 


Let’s say a patient comes in with abdominal pain and is diagnosed with appendicitis on abdominal CT. You should order a general surgical consult for appendectomy and antibiotics as well as the following since this person will be undergoing surgery: NPO, maintenance IV fluids, type and screen, PT/INR, PTT.


Health maintenance: 


Here are some common tests and vaccines as well as patient advice to think about for each case and order if they’re appropriate. Remember, always err on the side of ordering these if you’re not sure.

  • Tests and vaccines: Influenza vaccine, Shingles vaccine, Pap smear, colonoscopy, Tdap, STI screening, hepatitis C screening, mammogram, low-dose lung CT (to screen for lung cancer in smokers).
  • Advice: medication compliance, reassure patient, limit or cessation from alcohol, smoking cessation, diet advice based on clinical condition.





This is of course, by no means, an exhaustive guide of USMLE Step 3 case simulations. However, I believe this framework of approaching these cases can be quite helpful in helping you stay organized and earn the most points you can for each case!


Remember, adapt this approach to your own style and practice to find what works best for you. Good luck!


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